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Waste Tire Su. Bey & Inspection Report Inspection Reporf. Number ■ <br /> CalRecycle State of California I 1 - 1230370 <br /> CalRecycle 181(Rev.y(CalRecycle) Survey <br /> Survey- Form - Page 1 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> PartA- S_urveyBLUE OR BLACK INK PEN <br /> rBusiness Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> 7 1 <br /> Site Suffix: p 7 7 l 9 Routine Q Re-inspection Q Referral Q Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: �0_y1 �oQ4 v� COv� Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name ` ^ - -\ Inspected By Inspector <br /> Physical b0.�e s �YMcTj UYICT �"RT�Y \ e -�' 39 \ V , M <br /> 266Z �• �,�So�n �aY <br /> Inspection Date Q ( / ` O 1 <br /> 2- tGc_Wt�`n � G s2� Time In 1 Time Out <br /> Business Rep Title 2 Q 0 AM 0 AM <br /> ` 46 PM 2 10 PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 40 Passenger * Generator &Outdoor <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler Q Indoor <br /> O Q Inactive Q Truck <br /> Longitude - Q Planned Q OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> New Tire Dealer 0 Auto Repair Q Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder Q Other <br /> Part B - Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / mq/ m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXE N <br /> a <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> Lu <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q Other:§ <br /> Comments <br /> ,, x>.s <br /> Inspection Form Included: Q T <br /> Comments Included: <br /> Business Rep's Sig a Ph e N tuber An,, or's Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct:* Incorrect: � � V EXAMPLE 1 2 3 62081 <br /> ■ White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />